Provider Demographics
NPI:1912302787
Name:MIND, BODY & MODERN MEDICINE, LLC
Entity Type:Organization
Organization Name:MIND, BODY & MODERN MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:I
Authorized Official - Last Name:BEVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:727-992-3440
Mailing Address - Street 1:8341 CAROLYN DR
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-6210
Mailing Address - Country:US
Mailing Address - Phone:727-264-1364
Mailing Address - Fax:
Practice Address - Street 1:19401 SHUMARD OAK DR
Practice Address - Street 2:CLARITY MEDSPA
Practice Address - City:LAND O'LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638
Practice Address - Country:US
Practice Address - Phone:727-264-1364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9101970363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty